Electronic Eligibility Format Specifications

1 Eligibility Specifications July 2017

Web site: www.healthlink.com Email: [email protected]

HealthLink Electronic Eligibility Format Specifications

Version TDC.7.003 Purpose of Document This document describes HealthLink’s Eligibility Format Specifications for receiving eligibility information electronically for subscribers accessing HealthLink networks or products. Eligibility Format – New Client/Change Request Sheet HealthLink requires industry standard file types and specific information to correctly set up the HealthLink system and manage membership information, which is used to comply with privacy standards to appropriately identify, reprice and route claims to payors. The submitter (usually the payor) must complete the accompanying “Eligibility Format – New Client/Change Request Sheet” and return it to HealthLink. This form is also available on HealthLink’s Web page (www.healthlink.com) or by contacting the Enrollment Department. A new submitter (e.g. a new payor) is required to send a test file with the New Client form, and a copy of the file layout to our Enrollment department, during the implementation process to allow adequate programming and testing time if needed. Usually, this is 30 – 60 days prior to the group’s effective date with the HealthLink network. The Enrollment department reviews and loads the test file to ensure the format and methods of transmission are functioning properly. The FTP transmission methodology is established during the implementation process to be used for testing. The “Eligibility Format – New Client/Change Request Sheet” is used to communicate changes in the eligibility format such as media type, file format, or file frequency. Payors may send their file layout document with the notification sheet. Eligibility File Media and Transmission Types HealthLink receives eligibility files in one of the following ways from payors or the payor’s vendor:

FTP (File Transfer Protocol) with PGP encryption

SFTP (Secure File Transfer Protocol)

Email to [email protected]


FTP or SFTP is our preferred file submission methodology. The definition of FTP and frequently asked questions about FTP are found in the Payor Manual on our web site under TPA>Forms and Guidelines>Administrative Manual. The record for an employee (or primary member) and his/her dependents on the eligibility file must be in the same format or layout. HealthLink is able to accommodate the electronic receipt of full eligibility files from each payor, which is used to automatically update the records following each submission. Eligibility files are submitted in the standard eligibility format described in this document. If a submitter (payor) must use another format, we request that a copy be forwarded to HealthLink, in advance. HealthLink’s IT programming staff will review the request and notify the submitter whether the format can be accommodated, with a time estimate to set-up the format. Sending files in the standard format reduces errors, and greatly expedites the loading process. Use ASCII for all files. Full eligibility files include all members who are active, as well as terminated members. Once a member’s access to HealthLink networks has been terminated the member record should remain on the full file for three consecutive months. After loading the full eligibility file, HealthLink will email an eligibility confirmation report, which includes a summary of the client’s electronic eligibility file loading status. A sample confirmation report is found at the end of this document. HealthLink accepts ANSI 834 files. More information on submitting in the 834 format can be found on the HealthLink web page (www.healthlink.com), or by contacting the Enrollment Department. The ANSI 834 file format is designed for client groups to submit enrollment information to a health plan. 834 may be used for the network business, but care should be taken to include network access effective and termination dates, and specific network designations (as applicable). Files are usually submitted on a monthly basis. For large blocks of business (over 10,000 member records/file) more frequent transmissions are recommended.

New clients are contacted to establish a mutually agreeable “standard” submission date.

For established payors/clients, it is only necessary to complete a new sheet upon intent to make schedule changes or format changes from the current submission methodology.

It is imperative that the submitter (payor) send only HealthLink membership data on the files indicating the appropriate product and network access. Ancillary services sold through HealthLink may require modifications to the file data, and will be handled in a separate implementation process. Any membership information pertaining to business for which HealthLink is not responsible should not be submitted on eligibility files. Effective dates are those related to the HealthLink network access only.


Multiple Groups, Networks and Products Multiple Groups “Payor Group Numbers” are unique identifiers assigned by the submitter (payor) to identify each client group. HealthLink uses “payor group numbers” to load group records into our system.

The submitter (payor) needs to complete the “Payor Group Number” field (positions 1 – 15).

All groups are submitted on one file, identifying the different groups with unique group numbers. For example, a TPA should submit one file containing all groups’ membership records, not a separate file for each group.

The submitter (payor) must notify HealthLink of their group number configuration in advance of submitting the membership for a specific client group. HealthLink’s Enrollment Department adds payor group numbers into the HealthLink system, before eligibility data for the group can be loaded.

Without payor group number notification to Enrollment and the payor indicating the group information in the exact same configuration as the file (examples: leading digits or dashes between numbers), HealthLink is unable to identify the group and unable to load the membership, which delays the process and may result in claims service problems.

Multiple Networks “Network ID’s” are unique identifiers assigned by submitter (payor) to identify payors or groups that have access to more than one network. For example, if a payor or group has membership that has access to the HealthLink PPO network and membership that will access the HealthLink HMO (Open Access) network, a Network ID will need to be added to positions 20-24 to identify which network each member accesses. Multiple Network Products “Product Codes” are unique identifiers assigned by the submitter (payor) to identify payors or groups that have access to more than one network product. For example if a payor or group has membership that accesses the PPO network product and other membership that has access to the Open Access II network product, a product code will need to be added to positions 25-27 to identify the network product for which each member accesses.


HealthLink Electronic Eligibility File Specifications

Character set: ASCII Format: Fixed Width File Name: (see File Naming Convention)

File Naming Conventions: File naming conventions apply to the file ID for FTP files, and email files. For email files, the Client ID should be included in the email subject and body of email, using the following naming convention. The file name should appear similar to “H12340501”.

(1) The file name is a nine character ID with first character being either an H or T. (a) “H” meaning production file (b) “T” meaning test file

(2) Character positions 2 – 5 contain the Client’s ID number assigned to each unique electronic file received. In our example the client ID is “1234”

(3) Character positions 6 – 7 indicate the 2-digit month the file was generated. In above example, the month is “05” for the month of May.

(4) Character positions 8 – 9 contain the 2-digit day the file was generated. In the above example, the day is “01” for the first day of the month.

For FTP Files, the file name should appear similar to “ELIG_20040702_001.PGP.

(1) The file name is a twenty-two character ID with the first four characters being

ELIG (2) Character positions 6 – 9 contain the 4-digit year the file was generated. In our

example the year is 2004. (3) Character positions 10 – 11 contain the 2-digit month the file was generated. In

our example the month is “07” for the month of July. (4) Character positions 12 – 13 contain the 2-digit day the file was generated. In

our example, the day is “02” for the second day of the month. (5) Character positions 15 – 17 contain the sequence number if multiple files are

being sent on the same day. The sequence number will always be 001 for the first file submitted; any additional files submitted on the same day will follow the same sequence pattern. In our example the sequence number is 001.

(6) Character positions 19 – 21 contain the PGP extensions as all files submitted to HealthLink FTP server are required to be encrypted with the HealthLink PGP key.


Clarification About Member Terminations: For the purposes of this document:

“Insured”, “Subscriber” and “Employee” have the same meaning, and represent the primary party with coverage under the payor’s health benefit plan.

“Member”, “Covered Person” and “Dependent” denote any person covered under the payor’s health benefit plan that can be either an employee or a member of their family (spouse or children).

“Insured” = Subscriber or Employee or Primary Member

“Member” = Covered Person, Dependent, Employee, Insured or Subscriber

File Layout Specifications with Field Descriptions Key:

Position: Placement in the field Length: Number of characters allowed for the field Type: “AN” = Alpha-numeric (left justified in a field of spaces); “N” = Numeric (Right justified in a field of zeros) Required: Y (Yes); N (No)

Field Name Position Length Type Required?

Payor Group Number 1 – 15 15 AN Y Payor group numbers are unique identifiers assigned by the submitter (payor) to each group. Eligibility information is included for all client groups on the same electronic eligibility file with the “Payor’s Group Number” field populated. HealthLink uses the payor’s group numbers to load groups into the HealthLink system. The submitter (payor) must provide HealthLink with their group numbers for HealthLink’s Enrollment Department to add these records into the system for identification prior to submission of the membership records. Without these group records and numbers, a significant delay will occur to the load of the membership, since HealthLink will not be able to identify the group without calling the payor for the information and re-loading the eligibility file. The group notification forms is available on the HealthLink web site.

Location Code 16 – 19 4 AN N Segregation of a group’s eligibility due to specific locations, branch numbers, benefit levels, account codes, unit, numbers, etc., requires a location code added to the group number. It is a best practice to combine the location code with the payor’s group number, as a suffix, appearing at the end of the payor’s group number. Example: A group has three branch locations. The group’s number is “12345”; the office locations are 01, 02 and 03. The group number field would be:


1234501 for a record indicating location 01

1234502 for a record indicating location 02

1234503 for a record indicating location 03 Note: This only applies to a specific group requiring a separation of their eligibility due to reporting requirements, affiliated networks use or special products usage for subdivisions of a client group.

Network ID 20 – 24 5 AN N Network ID’s are used to identify which network the member will access. These are only required for files that contain membership for more than one network.

Product Code 25 – 27 3 AN N The product code is a unique identifier assigned by the submitter (payor) to note groups using more than one of HealthLink’s network products. An example is for segregating member records with PPO network access from those with Open Access II network access.

Name of Group 28 – 57 30 AN Y This field is for the payor’s group name associated with the specific payor’s group number. If the file contains multiple groups, each group should have a different group name.

Insured’s Social Security Number 58 – 66 9 N Y Use the Social Security Number of the insured to identify the insured, as well as associate all his/her dependent records with this master record.

Insured’s Policy Number 67 – 96 30 AN N If Social Security Numbers are not used to identify the insured, then use this field for the payor’s policy number. In many instances, the Social Security Number of the insured is the policy number, in which case, this field is not used. Use this field for the payor’s Privacy ID number. Provide both the Insured’s SSN (see field above) and the Policy or Privacy ID numbers when used. This facilitates cross-referencing with our records. Many providers utilize the insured’s SSN, even when payors use special policy or privacy numbers.

Member’s Number 97 – 98 2 N Y “00” = Insured “01” = Spouse “02” = Dependent “03” = Dependent, increased sequentially for additional dependents


Member’s Last Name 99 – 123 25 AN Y

Members First Name 124 – 138 15 AN Y

Member’s Middle Initial 139 1 AN N

Member’s Address – line one 140 – 169 30 AN Y

Member’s Address – line two 170 – 199 30 AN N

Member’s City 200 – 214 15 AN Y

Member’s State 215 – 216 2 AN Y

Member’s Zip Code 217 – 225 9 N Y

Member’s Phone Number* 226 – 235 10 N Y *Include area code. Do not use any punctuation.

Member’s Birth Date 236 – 243 8 AN Y Format: MMDDYYYY For example, January 1, 2000 would be entered as “01012000”, designating a 4-digit year.

Member’s Gender 244 1 AN Y “M” = Male “F” = Female

Member’s Relationship to Insured 245 1 AN Y “1” = Insured “2” = Spouse “3” = Dependent “4” = Student “5” = Other

Member’s Status 246 1 AN Y

“A” = Active “T” = Terminated This is the status of membership with the HealthLink network. In the event the group and membership change from one network product to another, such as PPO to Open Access II, the PPO record should be terminated on one date, and the Open Access II member record with an OA II indicator become active the following date. Without this distinction, claims will not be processed correctly with the correct network access or network product access.


Member’s Effective Date 247 – 254 8 AN Y Format: MMDDYYYY For example, January 1, 2000 is “01012000” to indicate the 4-digit year. Indicates the effective date with the network or specific network product. This effective date (and termination dates) point our system to the proper claims repricing procedures.

Filler (Not Used) 255 1

Member’s Termination Date 256 – 263 8 AN Y Format: MMDDYYYY For example, January 1, 2000 is “01012000”. Note: If a member’s network access or network product type is terminated, a termination date is essential. A termination date is used only if the specific record is terminated, and is not used for future or default termination dates. For unions with members in hour banks, terminate the member record when the member moves out of town, or no longer would have network access. The member record should not be changed “on and off”, such as when the union member’s hours of service temporarily change (the record should stay on the file).

Insured’s Contract Type 264 – 265 2 AN N “S” = Single “F” = Family “EC” = Insured and Child “ES” = Insured and Spouse It is very helpful if the member number (i.e., 00, 01) assigned to an individual member remains the same, when adding or terminating dependent(s).

Designate a new number for each new member. This includes the addition of a new spouse or dependent.

Do not change the number assigned to existing members or reassign the number to a new spouse or dependent.

For example, if an insured is divorced and then remarries, the original spouse is terminated and a new spouse (and member number) is added. The same relationship member number on the new member should not be re-used, as was assigned to the previous member record. Assign the new member the next available member number. In the event that this cannot be accommodated, we should be notified so automated loading of files can function properly. Terminating the primary insured record, doesn’t automatically terminate the associated dependent records.


Individual Coverage Flag 266 1 N N This flag is used when a submitter (payor) has “Individual Policies”; meaning that the insured does not belong to a specific client group. HealthLink will place the individual insureds records into a single or global group to avoid the confusion of creating an individual group for each insured record. In such situations, the Individual Coverage Flag can be used to indicate that, while the different insureds do not have the same group or policy number, they can be treated as one group for HealthLink’s purposes. Placing individual insured records into global groups, segregated only when network access or product type are different, provides the best claims repricing service. For example, a payor with some individual health insureds with PPO network access will be placed into one global group, and another global group would be used for those individuals with the Open Access III network program plan.

PCP – Number 267 – 272 6 N N* This is the HealthLink six-digit provider number of the member’s primary care physician. Note: This field is optional. It is not necessary for other network products.

PCP Effective Date 273 – 280 8 N N* Format: MMDDYYYY For example, January 1, 2000 is “01012000” This is the date that the member’s primary care physician (PCP) was assigned. Note: This field is optional. It is not necessary for other network products.

Other Address – Line One 281 – 310 30 AN N The other address fields can be used if the member has a second address that should be used for correspondence instead of the regular address.

Other Address – Line Two 311 – 340 30 AN N

Other Address – City 341 – 355 15 AN N

Other Address – State 356 – 357 2 AN N

Other Address – Zip Code 358 – 366 9 N N


File Layout Specifications-Simple Layout

Field Name Position Length Type Required?

Payor Group Number 1 – 15 15 AN Y

Location Codes 16 – 19 4 AN N

Network ID 20 – 24 5 AN N

Product Code 25 – 27 3 AN N

Name of Group 28 – 57 30 AN Y

Insured’s Social Security Number 58 – 66 9 N Y

Insured’s Policy Number 67 – 96 30 AN N

Member’s Number 97 – 98 2 N Y

Member’s Last Name 99 – 123 25 AN Y

Member’s First Name 124 – 138 15 AN Y

Member’s Middle Initial 139 1 AN N

Member’s Address – line one 140 – 169 30 AN Y

Member’s Address – line two 170 – 199 30 AN N

Member’s City 200 – 214 15 AN Y

Member’s State 215 – 216 2 AN Y

Member’s Zip Code 217 – 225 9 N Y

Member’s Phone Number 226 – 235 10 N Y

Member’s Birth Date 236 – 243 8 AN Y

Member’s Gender 244 1 AN Y

Member’s Relationship to Insured 245 1 AN Y

Member’s Status 246 1 AN Y

Member’s Effective Date 247 – 254 8 AN Y

Filler (Not Used) 255 1


Member’s Termination Date 256 – 263 8 AN Y

Insured’s Contract Type 264 – 265 2 AN N

Individual Coverage Flag 266 1 N N

PCP (HMO Only) 267 – 272 6 N N Note: This field is optional.

PCP Effective Date (HMO Only) 273 – 280 8 N N

Note: This field is optional.

Other Address – Line One 281 – 310 30 AN N

Other Address – Line Two 311 – 340 30 AN N

Other City 341 – 355 15 AN N

Other State 356 – 357 2 AN N

Other Zip Code 358 – 366 9 AN N


Eligibility Summary Confirmation Report

This confirmation report is designed to inform the eligibility submitter the status of and results of loading the latest eligibility file.

ClientName “American Health Insurance"

ClientID 1234

Date Received 7/11/2004

Load Date 7/12/2004

Total Records Read 100,000

Client Groups 5

HealthLink Groups 5

Summary Information:

Total Active Subscribers 9111

Unique Active Subscribers 9033

Total Active Members 22007 Sort Key

Unique Active Members 21875

Detail Information:

Client Group HL Group Num Total Subscribers Total Members 1234 PPK334 8977 19005 1234 LYI442 135 563

Wednesday, August 01, 2004


Email to: [email protected] HealthLink Enrollment Department

Eligibility Format

New Client/Change Request Sheet

This information is for (check one): New Client

Current Client, Requesting Changes

Whether you are a new client or a currently submitting client requesting changes, it is important to complete all fields. Please see the HealthLink Electronic Eligibility Format Specifications, available at www.healthlink.com, if you have questions about this form. Please notify us in advance of changes to file format, frequency or transmission methods.

Company (Payor) Name:

If Source Other Than Payor (Eligibility Vendor):

I.T. Contact Name:

Contact Phone & Extension:

Contact Fax Number:

Contact Email Address:

Submission Method: FTP/Email HealthLink

Type of File: Full Eligibility With 3 months of termination information

File Format: (If you are requesting a format other than the

HealthLink Standard, please attach a copy of the layout).

HealthLink Standard

834 with HealthLink Dates

Frequency of Submission: (Monthly or other. Please specify.) Monthly

Other ____________________

Week of Submission: (For monthly clients, what week of the month will

you send in the file) ____________________

Confirmation Reports To:

For use by HealthLink IT Only: Client's ID: ____________________

Documents

Electronic Eligibility Format Specifications